Veterans Affairs: 5th HIV Case Linked to Unsterile Equipment

From CDC National Prevention Information Network

May 4, 2009

On Friday, the US Department of Veterans Affairs announced that seven more hepatitis infections and a fifth HIV infection were discovered among patients exposed to unsterile endoscopic equipment at three VA hospitals. Of nearly 11,000 veterans who were potentially exposed to infectious diseases through colonoscopies or ear, nose and throat procedures, 6,787 have been notified of their hepatitis and HIV test results. The number of hepatitis cases found among the VA patients so far is 33.

The VA said in a news release that the infections are "not necessarily linked to any endoscopy issues"; however, the problems discovered recently had persisted for years.

The VA first learned in December that its Murfreesboro, Tenn., facility had not been following the scope manufacturer's instructions for cleaning the instrument. Problems were next discovered at the Augusta, Ga., VA hospital in January, and on Feb. 9 the VA announced a national safety check of the endoscopes. In March, the Miami VA hospital backtracked on its previous assessment that it had no problem with the equipment. The fifth HIV infection involved a Miami VA patient.

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The maker of the endoscopes, Olympus American Inc., has said its recommendations for cleaning the instruments are clear.

The VA and its inspector-general have started investigations, and the agency is releasing some information on its Web site. Congressional members of the Veterans Affairs Committee plan to hold a hearing in late May to discuss how the agency is handling the matter.

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